Innovative payment methods in healthcare: a realist literature review and
multiple case study
A joint thesis
MSc Business Administration Health
MSc Business Administration Strategic Innovation Management
Michiel Christiaan Huizer S2539802
Grote appelstraat 9 9712 VA, Groningen
Supervised by:
Prof. dr. ir. K. Ahaus - First supervisor Dr. I. Estrada - Second supervisor Faculty of Economics and Business
University of Groningen
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Abstract
This study carries out a realist literature review and multiple case study to uncover the inner
workings of innovative payment methods in healthcare. These methods have received an increasing amount of attention by researchers but results remain inconsistent. We specifically focus on pay for performance programs which aim to increase value for patients by providing financial incentives for key performance indicators. After a systematic literature search, 15 articles were analyzed. This resulted in five context-mechanism-outcome configurations. These configurations were verified and extended by analyzing four cases. Qualitative data from the cases were collected through semi-structured interviews. Results indicate that (regional) contexts and increased communication between parties are associated with enhanced value for patients. Additionally, we found that idea sharing networks and collaboration resulted in the development of overarching unified outcome measures. It is argued that these side-effects may have a greater impact on increasing value for patients compared to financial incentives. Managerial implications are provided from a healthcare and innovation perspective. Limitations and future research opportunities are discussed.
Keywords: healthcare innovation, VBHC, financial incentive, pay for performance, CMO
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Index
1. Introduction ...4
2. Methods ...6
2.1. Realist literature review ...7
2.2. Realist multiple case study ...9
3. Results ... 11
3.1. Realist literature review ... 11
3.2. Realist multiple case study ... 14
3.2.1. Hip/knee ... 14
3.2.2. Stroke ... 17
3.2.3. Diabetes ... 19
3.2.4. Anxiety & Depression ... 20
4. Discussion ... 22
5. Conclusion ... 24
5.1. Theoretical and managerial implications ... 24
5.2. Limitations and future research ... 25
6. References ... 26
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1. Introduction
In Western societies policy makers are increasingly concerned about the negative effects rising healthcare costs have on the accessibility of healthcare and the value for patients (Herzlinger, 2006). Physicians have difficulty carrying out new procedures due to unnecessarily high costs of care, and purchasing bodies are struggling to afford the same treatments (Bodenheimer & Fernandez, 2005). Additionally, increasing healthcare expenses pressure national economies and cost savings often result in decreased value for patients (Nichols et al., 2010). In reaction to these issues, Porter and Teisberg (2006) argued that a redefinition of health care is necessary and introduced the concept of Value Based HealthCare (VBHC) (Porter & Teisberg, 2006; Porter, 2009; Porter, 2010; Kaplan & Porter, 2011). One of the basic aims of VBHC is to achieve high value for patients when value is defined as “health outcomes achieved per dollar spent” (Porter & Teisberg, 2006, p.4). This implies that in order to increase value for patients, higher quality of care and/or a decrease in costs is required.
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Moon, 2013). With this understanding, resources may be used more strategically in order to gain a competitive advantage.
Omachonu and Einspruch (2010, p.5) defined health innovation as “the introduction of a new concept, idea, service, process, or product aimed at improving treatment, diagnosis, education, outreach, prevention and research, and with the long term goals of improving quality, safety, outcomes, efficiency and costs”. When also applying the principles of VBHC, innovative payment methods in healthcare should ultimately improve value for patients. However, despite the popularity among policy makers and insurers as a tool for enhancing value for patients, there is limited
empirical evidence for the effectiveness of new payment methods (McClellan, 2011; Milstein et al., 2016; Ridgely et al., 2014).Furthermore, findings are often mixed or found to be insignificant (Bonfrer et al., 2018; McDonald et al., 2015; Mullen et al., 2010).
The complexity of the context and mechanisms in healthcare might be one of the reasons why the literature on payment methods within the healthcare industry is scattered and does not show a unified approach to successfully implement these innovations. Despite the divided literature, an increasing number of programs are being developed and implemented. Without a clear
understanding of the innovative payment mechanisms, the risk of achieving sub-optimal healthcare outcomes or even lower value for patients is concerning. Empirical studies should therefore be of great value for policy makers, insurers, healthcare providers and patients (Van Herck et al., 2010). Most literature reviews and/or case studies would not be able to deal with the healthcare context, mechanisms and outcomes, which are often based on complex social systems (Pawson, 2006; Pawson et al., 2005). A realist approach, on the other hand, seeks to unpack the CMO relationships that are prevalent, while also explaining success, failure, mixed results and social complexities. Previous research has suggested that this approach is most suitable for this study (Pawson et al., 2005; Wong et al., 2013).
Given the mixed literature and the urgency to make healthcare sustainable again, it is crucial to add empirical knowledge to the current field. Therefore, this study aims to answer the following research question with regard to western societies:
How can context and mechanisms of innovative payment methods in healthcare influence health outcomes, care experiences, costs and physician experiences?
P4p schemes in healthcare strive to link predefined care targets to financial compensation in order to increase value for patients (Khanduja et al., 2009; Van Herck et al., 2011). In theory,
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quality improvement programs often have one overlapping goal; providing an opportunity to care organizations and physicians to benefit from improving value for patients instead of increasing care volume. These incentive schemes may therefore be more overlapping in practice than scholars think. With the lack of understanding of how these payment methods differ from each other in practice, this study aims to gain a better understanding of the implementation of p4p as an innovative
payment method within the healthcare system. The overarching purpose of this research is to extend the existing body of literature on innovative payment approaches in healthcare. A two-stage p4p research is conducted and as a result, Context-Mechanism-Outcome (CMO) configurations are synthesized and discussed. The two stages of this research include (1) a realist literature review and (2) a realist multiple case study and synthesis in the Netherlands to verify and refine knowledge that was obtained from the literature. In the next section the methodology of these two stages will be discussed. Results are then presented extensively followed by the discussion which primarily elaborate on the link between the two stages and the salient CMO configurations that emerged. Finally, a conclusion and corresponding managerial implications will offer practical advice to those who are involved in implementing innovative healthcare payment methods.
2. Methods
A realist review is described by multiple scholars as a study that explains what works for whom, under what circumstances, how and why (Pawson 2005; Wong et al., 2013). Certain interventions may be successful in one context but perform poorly in another. A realist review aims to find CMO configurations to best describe the implication of an intervention and the relationships between context, mechanisms, and outcomes. Contexts are settings in which the intervention was
implemented. For example, this may include geographical locations, a moment in time, culture, or a specific organization. A context may be an opportunity or constraint for an intervention, and can be a physical setting as well as a specific state or norm. Innovative payment methods in healthcare are most likely always implemented in pre-existing conditions. These conditions are almost never identical; therefore, it is key to analyze them (Pawson, 2006). Mechanisms are forces that closely interact with the context of an intervention and will generate outcomes (Kirsh et al., 2017). It allows us to uncover the reasoning why, for whom and under what circumstances something happened. In other words, through mechanisms we try to make sense of the world around us. Finally, outcomes are generated by context and mechanisms. These outcomes may be dynamic, meaning that
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theories (MRT) (Wong et al., 2013). These theories can help researchers and managers understand outcomes for payment innovations in healthcare.
2.1. Realist literature review
First, a realist literature review was conducted. This review initially contained the exploratory search terms ‘’Pay for Performance’’ and ‘’Healthcare’’. In addition to these search terms, a variety of articles were recommended by experts related to this research. The articles of Bonfrer et al. (2018) and Edmonson et al. (2001) were studied to gain knowledge about p4p programs, innovation in healthcare, and to specify more detailed search terms. Additionally the articles of Tranfield et al. (2003) formed the foundation for the systematic methodology that was carried out. Realist studies seek to deconstruct and analyze interventions (Pawson et al., 2005), therefore, grey literature was also included during the initial literature search to expand our knowledge concerning p4p
interventions. Experts recommended the use of Skipr and Qruxx (Qruxx, retrieved 2019; Skipr, retrieved 2019) as databases for potentially useful grey literature. Included databases for the literature search were PubMed, Google Scholar and Web of Science (Medline). During the initial exploratory search these databases consisted of the most relevant studies in the field of payment innovations in healthcare.
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three case control, three randomized controlled trials, one case study/report, and one systematic review (Tranfield et al., 2013). The variety of the level of the empirical evidence was not regarded as a validity and/or generalizability issue since in a realist review, all studies are sources that contain elements that can enrich the understanding of the research issue (Pawson et al., 2005). Figure 1 illustrates the search strategy and the steps that were undertaken during the literature review. Table 1 provides an overview of the selected case evidence level.
Table 1: Overview of the literature evidence level
Type of case study Number of cases Percentage of total
Systematic review 1 6,5%
RCT 3 20%
Cohort study 7 47%
Case controlled study 3 20%
Case study/report 1 6,5%
The data from the selected empirical articles has been extracted by coding and analyzing the information. The three main coding categories, context, mechanisms and outcome, were each assigned to one color. In certain papers, multiple sub-codes were found. For example, in the paper of Hackett et al. (2014), low socioeconomic status and specific diseases, such as osteoporosis and obesity, were both sub-codes for context. In the article of Milstein and Schreyoegg (2016) a clear implementation strategy and indicators that are aligned to health outcomes were important
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Figure 1: Overview of literature search flow
2.2. Realist multiple case study
Independent from the literature, a multiple case study has been conducted to find additional CMO configuration support for p4p in western healthcare systems. Because of the accessibility to multiple cases through the Linnean initiative, all cases were set in the Netherlands. Furthermore, Dutch healthcare is seen as one of the best care systems in Europe while also being one of the most expensive (Kroneman et al., 2016). This offered an interesting opportunity to study p4p in an organized care system. In order to fully understand the environment in which these cases are set, a basic understanding of the Dutch healthcare system is fundamental.
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insurance package premium for the following year. This package is largely paid for by compulsory health insurance payments from citizens. The insurers are required to accept all applicants and often have to take the stakes of patient organizations, hospitals, the government, other insurers and care professionals into account. In other words, Dutch insurance companies purchase desired care from providers, and in doing so, they divide the monetary funds received of the insured population (Van der Pennen et al., 2015). The competitive healthcare insurance market is dominated by four large organizations. When a patient requires treatment, they often first have to see a general practitioner (GP) who then might refer the patient to the hospital. The GPs can be seen as the gatekeepers to further and/or specialized treatment. This type of care is called primary care. Hospitals are referred to as the secondary care. The healthcare professionals in hospitals have a very strong position in Dutch healthcare system because they represent a large portion of the hospital’s core business. Care organizations, such as nursing homes, belong to the tertiary care. Currently, most healthcare
providers all have access to an electronic patient record system; however, these systems are limited since they do not allow for interconnections between multiple providers (Kroneman et al., 2016).
While this disconnection between providers remains a flaw within the Dutch healthcare system attention for VBHC has grown in the Netherlands since the research of Porter and Teisberg (2006). The Linnean initiative is one example of a network of Dutch experts who are aiming to actively stimulate patient value driven healthcare (Linnean, retrieved 2019). In collaboration with the Linnean initiative, cases were selected on multiple criteria. First, we intended to select a variety of cases, meaning that we focused on acute, planned, chronic, mental and/or physical care. Studying a variety of cases allows for multiple contexts to be analyzed which added information and diversity to the overall qualitative data set while reducing potential for biases. Because this study was carried out alongside a bundled payment study, the second selection criteria was based on disease specific characteristics including hip/knee, stroke, diabetes, cardiovascular, and anxiety/depression treatments. Boundaries to the interviews were set and a clear patient journey could be discussed during it. It was important to include as many perspectives as possible to uncover the inner workings of p4p and to expose the financial, analytical and practical side of these programs. It was decided to contact one data analyst or manager/advisor, one insurer and one care professional, involved in the implemented p4p program by email. GPs and patient organizations were not included in the
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regarding their participation within this research by signing the consent document which was handed out prior to the interview. The majority of the respondents were employed by one of the large insurance organizations in the Netherlands. Table 2 shows an overview of the interviews that were carried out and the corresponding characteristics.
Table 2: Overview of the disease programs/characteristics, number of respondents, and their positions
Condition Data analyst/advisor Insurer Care professional
Hip/Knee xx xx x
Stroke x x
Diabetes x
Cardiovascular
Anxiety/depression x x
All interviews were transcribed. The average number of words was 7487 (longest: 13914, shortest: 3748). The transcriptions of the interviews were all documented and imported into Atlas.ti for inductive qualitative analyses. The documents were grouped according to type of disease. This resulted in 4 distinct document groups; hip/knee, stroke, diabetes, and anxiety & depression. Every code was assigned to a color group during the analyses. Afterwards, these groups were used to distinguish between context, mechanisms, outcomes, innovation related, and p4p related data. Multiple codes we sometimes group together due to their similarities. Often, these codes were all related to an overarching construct. For example, “patient volume” and “financial volume” were grouped under the code “volume” since both of these constructs were used by respondents to describe the importance of overall treatment volume.
3. Results
3.1. Realist literature review
A total of five CMO configurations (CMOcs) were found in 15 empirical articles. Below, these CMOcs are elaborated on and presented in Table 3. Each configuration is discussed individually and include: (1) Voluntary participation enhances support for the program and intensifies collaboration
between parties. In doing so, value for patients increase and strong idea sharing networks are established.
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(3) Feasible programs make participants aware of the quality improvement goals and facilitates learning and dissemination. This results in positive spillover effects. (4) Heavy workload settings combined with a lack of resources make physicians feel
detached from the intervention. A mismatch and tension between parties results. (5) The level of quality (improvements) between care providers and financial incentive size
increase outcomes for patients.
CMOc 1: Voluntary participation enhances support for the program and intensifies collaboration between parties. In doing so, value for patients increase and strong idea sharing networks are established.
Voluntary p4p programs were found to be able to stimulate the number of motivated participants in the program (Bardach et al., 2013; McDonald et al., 2015). An increased number of intrinsically motivated participants increased the support for the corresponding program. Increased support was key to the importance of the implementation of the program (context). Due to high intrinsic
motivation, collaboration between parties intensified. This collaboration is best carried out when a positive attitude towards change and commitment to the new intervention is established. Using pilot interventions is a recommended approach (Van der Pennen et al., 2015). Collaborative learning events are key in building sustainable relationships (mechanism). This context combined with the mechanisms result in a positive impact on value for the patient. Furthermore, idea sharing networks are most likely established by the increased interdisciplinary discussions and collaboration among participants (outcome).
CMOc 2: Care treatment pathways that are relatively easy to standardize were supported by an EPR system and data managers. Modest care improvement followed.
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mechanisms in this setting led to modest improvements in chronic care and reduced resistance among participants towards the intervention (outcome).
CMOc 3: Feasible programs make participants aware of the quality improvement goals and facilitates learning and dissemination. This results in positive spillover effects.
In the literature, the importance of a feasible p4p is highlighted. Between regions a multitude of characteristics could be different. Examples of these characteristics include different relationships between the involved parties, as well as the amount of budget and/or the intensity of competition (Van der Pennen et al., 2015; Werner et al., 2011) (context). A feasible p4p program is relevant to a context. Commitment to the intervention is important. Additionally, continuous learning and dissemination of the intervention throughout the care organizations increase awareness of the program. Awareness of the intervention is low when participants are not aware of the outcome indicators that are being measured (mechanism). In the article of McDonald and Roland (2009) it is argued that a lack of awareness decreases the sense of ownership among care professionals. Awareness at the managerial level seems to positively impact short term effects of p4p programs. However, these effects are diminished when awareness is not disseminated through care
organizations. Furthermore, dissemination of the quality improvement program results in positive spillover effects throughout the organizations’ and participants’ surroundings. According to McDonald et al. (2015), increased value for patients not included in the program is considered as a positive spillover effect (outcome).
CMOc 4: Heavy workload settings combined with a lack of resources make physicians feel detached from the intervention. A mismatch and tension between parties results.
In a context of heavy workload for care professionals and complex care pathways, unintended effects of p4p are salient. In a complex care pathway, quality outcome indicators are hard to develop
(context). Data collection by care physician is burdensome due to the lack of resources, and more specifically, time. A third party that is put into place to support the data collection process could be assigned. However, mechanisms, such as a decreased sense of clinical autonomy and the lack of understanding of the program quality indicators, are observed (Lester et al., 2013) (mechanism). In turn, these mechanisms result in a mismatch between the expectations and observations of care professionals and the third party in charge of the data analysis. Frustration, resistance, and
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CMOc 5: The level of quality (improvements) between care providers and financial incentive size increase outcomes for patients.
In many p4p programs, participants are encouraged to deliver improved quality of care based on key performance indicators (KPIs) (Khanduja et al., 2009; Van Herck et al., 2011). In a context of rewards based on incremental provider improvement (context), financial incentives are often chosen. The size of the financial rewards is found to be different in many interventions (mechanisms). Increasing the size of the reward is associated with enhanced quality of care. In other words, care professionals tend to deliver higher quality of care when the potential bonus they can earn is higher. However, this impact is found to be relatively small (Navathe et al., 2019; Vainieri et al., 2018) (outcome).
Table 3: Summary of the CMOcs results from the realist literature review
Characteristic Context Mechanism Outcome
1. Collaboration Voluntary participation Increased support for the program Collaboration and communication
Enhanced value for patients and idea sharing networks 2. Data support Straightforward
treatment
Standardized indicators support of EPR system
Enhance quality of care
3. Spillover effects Regional feasibility Awareness and active coaching participants
Positive spillover effects
4. Resistance Heavy workload Scare resources participants feel detached from the program
Mismatch and increases tension between involved parties
5. Incentive size Quality of care program design for providers
Large financial bonus size
Increase quality of care for patients
3.2. Realist multiple case study
The realist multiple case study is carried out to verify and extent the current CMOcs. First, each case is presented extensively. The resulting CMOcs will be elaborated on after every case. The
corresponding CMOcs are presented in Table 4. 3.2.1. Hip/knee
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insurer, was high because they felt an urge to change the negotiations with care providers towards quality of care for patients, instead of financial analysis. After extensive communication with hospitals and physicians a voluntary quality improvement program was developed by the insurer. The role of the Dutch government was not mentioned in any of the four corresponding interviews. Important contextual variables that were mentioned by the respondents were all related to the feasibility of the program to the specific context. The potential volume of the program was indicated to be important for the future perspective of the quality improvement initiative. Most participants stated that in order to devote resources to the program, there should be enough time and treatment volume to earn back their investment.
“As insurers, we ask hospitals to put effort in the program and to come up with improvement
plans. These hospitals have to invest resources. We do not want to make these hospitals invest resources if they will only participate for one year. That’s why we offer a program to which they
commit for at least 3 years.” – Respondent 2, insurer
In the context of hip/knee, treatment volume was considered high and the providers signed a multiple year contract. Also, in this context variability between providers is high. This implies that there is room for improvement. According to the respondents, without this high variability, financial incentives to do better would not spark idea sharing nor innovative thinking. During the development of the program, the physician organization issued a negative advice to participate in the program. Despite this negative advice, 23 hospitals voluntarily participated in the program. The project officially started January 1st 2018.
The increased communication between the involved parties, initiated by the insurer, was mentioned by all respondents as an important mechanism. Especially care providers and analysts indicated that this was key to the acceptance of the program.
“We often perceive the insurer as a party who transfers hospitals the money, with or without
the expert knowledge of the corresponding treatments. Therefore, we found it very pleasant that they started to communicate with us. They wanted to know what our viewpoints and thought were on
good care outcome indicators. That was nice.” – Respondent 1, care professional
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improvement plans. This responsibility may have sparked a sense of ownership over the project and trust between the parties. Multiple respondents indicated that “just starting” was also important to the program. By this they meant that starting on a small, voluntary scale with a group of intrinsically motivated participants was a way to continuously develop and jointly enhance the quality
improvement program. In doing so, the level of risk is diminished due to the small scale while maintaining high support for the program. This allowed parties to gain experience in the implementation of the program. Currently, this process is still developing. Dissemination and interdisciplinary expansion of the project in this context was indicated to be the goal of all respondents.
Despite the presence of an EPR, which only provides patient data, care outcome data to determine the quality of care was not yet available. This makes it hard to indicate the effects of the financial incentive program for hip/knee treatments. However, in a context of hip/knee treatments and the corresponding mechanisms, outcomes were still salient. Due to the program, idea sharing between involved parties was stimulated. All respondents clearly indicated that multidisciplinary communication and collaboration between providers created a shared culture of mutual support and idea sharing. Additionally, an overall uniform benchmark was developed. Respondents reported that this is key to the success of the financial incentive schema because it enables them to compare providers, outcomes and value for patients while avoiding a focus solely on the financial side of healthcare.
“It is very important that quality of care outcomes are continuously being measured. Currently this is
already done by PROMs. In doing so, hospitals are not able to prefer financial goals over the quality of care for patients. That’s why measuring outcomes is tremendously important. The lack of quality of
care outcome measures is one of the major reasons why we can’t expand our programs.” –
Respondent 2, insurer
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depreciations into account. These two approaches resulted in contradicting financial data on hip/knee treatments and confusion among the involved parties.
In a voluntary p4p program, communication and collaboration are important to enable alignment between all involved parties. The feasibility p4p to the context is indicated to be key to the implementation of the program. Feasibility includes high variability in treatment costs and outcomes between care providers, the availability of treatment specific data, and the volume/the potential to scale up the project and enhance its impact in the future (context). Increased communication and collaboration are mechanisms that are generated by the supportive context. A clear task and responsibility distribution enables every party to focus on their specialty within the program. Additionally, care providers are made responsible for their own incremental improvement (mechanism). This context with these working mechanisms are found to results in intermediate outcomes. Idea sharing in interdisciplinary meetings is enhanced and an overarching unified set of quality indicators was developed. However, a misfit on the financial side of the program is an
unintended outcome. Analytics on the care professional side apply a different approach to treatment costs compared to the financial department of care organizations (outcome).
3.2.2. Stroke
Interestingly, care providers were already working together in a stroke service group before the financial incentive plan was initiated. In the year 2014/2015 stroke treatments became, as indicated by the respondents, a hot item. The increased attention by medical advisors resulted in the quality improvement program for 100 stroke patients at five care providers that started January 1st 2019. The three year development time prior to the realization of the project was needed to overcome the complexity of the context. Due to the fact that the outcomes of stroke treatments are not solely the responsibility of the hospital, the project was designed to comprise the whole care pathway.
Especially secondary and tertiary care providers are required to work together more closely. Consequently, the complexity of measuring financial and quality related outcomes increased. Intrinsic motivation of the initiators and care physicians were indicated to be high. In contrast to the hip/knee case study, patient organizations are actively included as part of the program because of the nature and the impact of the treatment.
“The development of the program took this long because it took a lot of time to uncover what the
financial impact for every involved party would be.” – Respondent 1, insurer
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care providers is a major part of the program. Secondly, the volume of stroke treatments was indicated to be relatively low (100 patients). To have a big impact on quality and costs, it was reported that higher treatment volume is key for future interventions. Lastly, due to a lack of resources, no extra IT support was made available until the date of the interview.
In relation to the context, interdisciplinary project groups were composed. These groups consisted of care professionals from different backgrounds, including managers, insurers and advisors. This allowed for intensive communication and collaboration between the involved parties. Furthermore, the program required increased data management by both the care providers and insurers. Financial and quality data was analyzed by the insurer and communicated back during the interdisciplinary meetings. Collecting the specific data was a result of the intervention and its context. During the project, a clear tasks distribution also emerged. Care professionals were made responsible for the overall care path and the development of quality outcome measures, while the insurer could be seen as the overseer of the program. In other words, care professionals chose a certain direction while the insurer guided them. This interconnectedness of parties requires a major investment of resources over time.
Quality of care outcomes were not yet available in this case due to the fact that the program has only been active for less than half a year. However, because of the increased collaboration and investment of resources, intermediate outcomes were already salient. Respondents mentioned that the development of the project also served as a learning opportunity. The complex yet small scale nature of the context allowed involved parties to discover flaws or imperfections while keeping the risk to a relatively minimal level. Continuous learning was reported to be important in this case. Another intermediate result was the development of a care outcome and the availability of a benchmark. These outcomes encompass the whole care pathway. This was found to be necessary because all care providers were made responsible for the final value for patients. The care path is transforming from individual responsible care specialists to a virtual stroke treatment center.
“The different care providers have basically become one virtual stroke treatment center. Together,
instead of their own specialized organization, they have become responsible for the whole care pathway.” – Respondent 1, insurer
Respondents indicated that the ultimate goal is to disseminate the financial incentive program. The biggest challenge is to overcome the contextual differences between regions. In the current stroke context, care providers were already working together to obtain a certain level of care quality. This is not the case in other regions. It was therefore indicated that context specific
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“We might discover effects that we did not anticipate on. We want to take those into account. If the
program works, we would also like to implement it in other regions in the Netherlands. In that case, collaboration is dependent on the context. When it is up to me, we should maintain the same level of
collaboration, and come to the same agreements about outcomes within the programs.” –
Respondent 1, insurer
In the context of stroke treatments in the Netherlands, communication relations between care providers are already pre-existing. Complexity of the p4p is high due to the inclusion of the total care path (primary-, secondary-, and tertiary care). The potential to improve outcomes, high intrinsic motivation among the initiator(s) of the program, and the potential impact on finances and care outcomes are indicated to be key contextual variables to the successful implementation of the program. The program is implemented on a small scale (context). An active mechanism that is associated with this context is increased data management. More resources were devoted to communication and collaboration due to the program. A clear tasks distribution was salient as care providers are made responsible for the quality of care whereas the insurer focused on financial data (mechanism). As a result, multidisciplinary interaction is stimulated. Furthermore, idea sharing and continuous learning by the network of participators was enhanced. Similar to the hip/knee case, a unified quality benchmark is developed (outcome).
3.2.3. Diabetes
In the setting of diabetes, the quality improvement program was initiated by highly intrinsic motivated care professionals. It was indicated that, because diabetes is a chronic disease, it is relatively easy to collect patient data and predict the treatment path. The availability of a clear benchmark and care standardization made it possible to form a solid basis for this intervention.
According to the respondent, support by the government stimulated the dissemination of the project. Around the same time as the implementation took place, the minister of health announced that VBHC experiments would be supported with additional funds and resources. In his message he shared a vision for healthcare in five to ten years. In line with the other cases, a secure long term goal for the future was needed for participants in order to devote resources to the program. Without it, providers feel too insecure to participate because it is relatively unknown if resource investments will be earned back. The respondent also pointed to the fact that taking context in mind is key to evenly distribute risks.
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insurers whereas we should design these interventions for care providers.” – Respondent 1, Data analyst/advisor
In order to safeguard the success of the implementation process, multidisciplinary groups were composed. These groups developed an implementation approach on finances, communication and care indicators. Resistance was indicated to be low because diabetes care is primarily provided by GPs. The impact that this program had was estimated to be around 5% of their total yearly income. Diabetes treatment is relatively straightforward and often performed by GPs/primary care. The availability of treatment specific data is high due to the EPR. Because of the large number of diabetes treatment, the impact of the program is considerable. Similar to the other cases
participation is on a voluntary basis. Intrinsic motivation of all participants is high because a clear vision of the future was present (context). Long term commitment (three years or more) is key to find support for the program. Interdisciplinary groups stimulated collaboration and communication between the involved parties (mechanism). Unofficial early results are increased quality of care for patients (lower mortality rate) but also increased costs (outcome).
3.2.4. Anxiety & Depression
In the contexts of hip/knee and stroke treatments an extensive communication process was conducted prior to the implementation of the quality improvement intervention. In the setting of anxiety & depression this phase was shorter, most likely because it gained attention only 2 years ago. Intrinsic motivation among the initiators was high. According to the respondent, anxiety &
depression represent the majority of mental health diseases. Furthermore, outcome related data was already being collected and showed big differences between providers. Due to these reasons, and inspired by other VBHC initiatives, the insurer decided to initiate the quality improvement program. The anxiety & depression patient organization was reached out for to provide feedback on the design of the project. Unfortunately they reported back that, as a patient organization, they were already involved in too many projects. Soon after the development of the program, it received a lot of negative media attention. Respondents indicated that a small majority of the care physicians were against the initiative because of uncertainty associated with the measurement of care outcomes. Anxiety & depression as a disease and the corresponding treatments were argued to be hard to objectively measure. Participation was voluntary and providers were offered a three year plan they had to commit to.
“In mental healthcare we are not as far with measuring effectiveness of treatments as medical
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objectify the outcome values for patients with a broken leg. In contrast, every depression is different and not easy to objectify.” – Respondent 1, insurer
The contextual factors led to multiple intended as well as unintended mechanisms and outcomes. The communication between the involved parties increased and it opened up the discussion regarding quality of care for mental health illnesses. However, in this particular context, support for the program decreased over time. Especially care professionals and organizations were found to show resistance. According to the respondents, these parties we not fully convinced about the validity of the outcomes that were going to be measured by a third party. Also, due to the media attention, stakeholders were hesitant to invest their resources and to commit to the program, especially at the board level. This resulted in a number of intermediate outcomes.
As a result of the discussions between the involved parties, five overall care outcomes were developed in collaboration with physicians. The respondent mentioned that these outcome
indicators were not linked to financial incentives anymore due to the resistance by multiple involved stakeholders.
“The mental healthcare organizations only wanted to participate in the program when outcomes
would not be linked to any financial incentive. Efforts to make financial reports more transparent were, however, not a problem.” – Respondent 1, insurer
Even though the intervention was not related to financial incentives it did increase interest in VBHC by care professionals. Furthermore, the first idea sharing meetings between 20 providers are now organized due to the implementation of the project. In line with the result from the emergency care/stroke case, respondents also indicated that they would like to work towards a virtual care team consisting of the current providers who are all responsible for the final outcome of a treatment.
The anxiety & depression p4p program is argued to be voluntary. Insurers, which are the initiators in this context, had high intrinsic motivation during the initial development of the intervention. A program for anxiety & depression has the potential to be scaled up. Additionally, patient data is available in the EPR system. However, outcomes for patients are not easy to objectify for this treatment (context). Negative (media) attention for the program and a lack of clear
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Table 4: Summary of the CMOcs results from the realist multiple case study
Characteristic Context Mechanism Outcome
A. Collaboration Voluntary participation Small scale pilot Potential high volume/impact
Increased support for the program Collaboration and communication Long term goals
Idea sharing network Established unified quality indicators Commitment B. Treatment characteristics Straightforward treatments Care outcome are objectifiable
Increased interdisciplinary collaboration and
communication Support of EPR system
Idea sharing network Established unified quality indicators Continuous learning C. Clinical autonomy Voluntary participation Small scale pilot Potential high volume/impact
Individual responsibility for data management and incremental improvement
Potential misfit of financial data between parties/departments D. Resistance Negative (media)
attention Resistance Lacking communication Increased awareness of VBHC/spillover effects No financial incentives Development of care quality indicators
4. Discussion
This realist review analyzed the innovative payment methods in healthcare, and in particular p4p, to explain how context and mechanisms influence health outcomes, care experiences, costs and physician experiences. Although most respondents actively participated in a quality improvement program, none of them reported to be directly involved in a p4p structure. Interestingly, most respondents indicated that they were engaged in a bundled payment or shared savings project which financially rewarded them if they were more efficient in delivering care. In other words, p4p was found to be an addition to other payment structures in many cases. The current literature discusses innovative payment methods as distinctive from each other. Scholars argue that p4p is primarily focused on rewarding care providers on KPIs (Khanduja et al., 2009). Bundled payment methods are aimed at paying a single fee for the whole bundle of care in one episode (De Bakker et al., 2012), and shared savings allows participants to receive rewards when healthcare costs are lower while
23
for VBHC payment programs. Currently, this may not have a major impact on health outcomes, care experiences, costs nor physician experiences. However, when these innovations gain momentum, this is a potential impediment to the payment methods. In order to redesign the way we pay for healthcare, all individual insurers, care providers, patient organizations and other involved parties, should agree on the same terminology, financial- and quality of care indicators. Without it,
healthcare providers become entangled in a complex web of different indicators which all aim to capture the same outcome. Moreover, in the literature, we found support for enhanced outcomes for patients when bonus size increased. Since p4p interventions often compliment other payment structures it calls attention to the relative bonus size compared to the overall budget of the participant. The CMOcs from the literature also show that understanding the context of the innovative method is key. These contexts trigger mechanisms which result in outcomes. We have seen that p4p programs for straightforward care pathways, supported by sufficient data
management and resources have a positive effect on the outcomes for patients. Additionally, the involvement of all parties and increased bonus size are argued to enhance outcomes for patients as well. Low awareness and resistance are shown to hamper the implementation process of innovative payment methods. In the multiple case study, support was found for the positive impact of data management, and the negative impact of resistance on outcomes for patients. Extensive interaction mechanisms between all the involved parties are an important extension of the CMOcs in the
literature. Innovative payment methods in healthcare should not solely focus on enhancing quality of care through financial incentives. Rather, these innovations have a broader impact on care outcomes by stimulating the development of unified definitions of care outcomes. This notion is supported by a recent article of Vlaanderen et al. (2019) who also argue that “other design features also influence the effects on quality of care and healthcare costs” (Vlaanderen et al., 2019, p. 229).
The resulting CMOcs from the multiple case study show little enhancement of outcomes for patients. This is largely explicable by the short time these programs have been implemented and the current unavailability of outcome data. Salient outcomes were the development of quality outcomes measures and increased idea sharing and collaboration within healthcare networks. This is an addition to the current literature which primarily aims to uncover improved quality of care. As previously discussed, it is of key importance that all involved parties communicate and collaborate with each other in an overarching network to create future value for patients. Rather than
24
(Williams, 2011). Similar to this notion is the research on contingency theory by Fiedler (1964) and Donaldson (2001). They argue that an organization is always dependent on the setting in which it is operating. This study provides evidence for the notion that the same holds for innovations in healthcare.
This study shows that contextual factors such as specific diseases/conditions, the potential impact of the intervention, and the availability of resources are key. Mechanisms such as,
communication, governance, bonus size, and awareness are interacting with these contexts. The results are in line with the innovation in healthcare framework of Greenhalgh et al. (2017). Although their NASSS (Nonadoption, Abandonment, Scale-up, Spread, and Sustainability) framework has been widely applied by scholars and managers, Greenhalgh et al. argue that it should be modified to fit specific contexts. By composing CMOcs which are verified in Dutch case studies, this research finds support for the NASSS framework and adds new insights into how context and mechanisms of innovation in healthcare contribute to (un)intended outcomes for health outcomes, care experiences, costs and physician experiences.
5. Conclusion
The aim of this study was to uncover the inner workings of innovative payment methods in
healthcare. The CMOcs show that the impact of these innovations are dependent on the context in which they are implemented. These contexts trigger a multitude of different (un)intended
mechanisms and outcomes. Innovative payment methods in healthcare are able to positively impact the value for patients under specific regional settings. Sufficient resources and engagement of all parties are important mechanisms which impact care outcomes and experiences. Additionally, we argue that the impact of unified care outcomes may have additional positive effects on health outcomes, care experiences, costs and physician experiences. It is of key importance that the healthcare sector works as one interconnected network which needs to collaborate and share resources in order to obtain better overall performance and value for patients. We suggest using a contingency approach to innovations in healthcare in order to have a better understanding of what works, where, and why can be obtained.
5.1. Theoretical and managerial implications
This study adds new insights to the literature on payment innovation in healthcare. Current research showed inconsistent results. Through this realist literature and multiple case study, contexts and mechanisms are uncovered which impact outcomes of financial incentive programs. These CMOcs can help scholars make sense of current and future reward based projects and innovations in
25
field. In assessing innovations in healthcare, scholars should carefully study the context in which the program is set and the mechanisms that are in place. In doing so, the underlying effects of an innovation are uncovered. Managers seeking to implement innovative payment methods in healthcare should take note of the underlying effects of the intervention. This study shows that transparent communication in any of the researched contexts is key. Establishing a clear communication network between all involved parties is shown to be beneficial to the outcomes program. Additionally, in a broader context, innovations in healthcare are shown to be hard to implement. We argue that this is due the complex contexts in which they are embedded. By applying a contingency approach, managers should fine tune interventions to their specific setting. To
diminish risks, managers can start small scale pilots in order to continuously learn, and adapt characteristics of innovations to specific needs of the context.
5.2. Limitations and future research
26
6. References
Bardach, N. S., Wang, J. J., De Leon, S. F., Shih, S. C., Boscardin, W. J., Goldman, L. E., & Dudley, R. A. (2013). Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial. Jama, 310 (10), 1051-1059.
Benavent, J., Juan, C., Clos, J., Sequeira, E., Gimferrer, N., & Vilaseca, J. (2009). Using pay-for- performance to introduce changes in primary healthcare centres in Spain: first year results.
Quality in primary care, 17 (2).
Bodenheimer, T., & Fernandez, A. (2005). High and rising health care costs. Part 4: can costs be controlled while preserving quality?. Annals of internal medicine, 143 (1), 26-31.
Bonfrer, I., Figueroa, J. F., Zheng, J., Orav, E. J., & Jha, A. K. (2018). Impact of financial incentives on early and late adopters among US hospitals: Observational study. bmj, 360, j5622.
Choi, J. N., & Moon, W. J. (2013). Multiple forms of innovation implementation: The role of innovation, individuals, and the implementation context. Organizational Dynamics, 42 (4), 290-297.
Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation science, 4 (1), 50.
De Bakker, D. H., Struijs, J. N., Baan, C. A., Raams, J., de Wildt, J. E., Vrijhoef, H. J., & Schut, F. T. (2012). Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Affairs, 31 (2), 426-433.
Donaldson, L. (2001). The contingency theory of organizations. Sage.
Doran, T. (2008). Lessons from early experience with pay for performance. Disease Management &
27
Edmondson, A. C., Bohmer, R. M., & Pisano, G. P. (2001). Disrupted routines: Team learning and new technology implementation in hospitals. Administrative Science Quarterly, 46 (4), 685-716.
Fiedler, F. E. (1964). A contingency model of leadership effectiveness. Advances in experimental
social psychology, 1, 149-190.
Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., Hinder, S., ... & Shaw, S. (2017). Beyond adoption: a new framework for theorizing and evaluating nonadoption,
abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. Journal of medical Internet research, 19 (11), 367.
Gulati, R., Nohria, N., & Zaheer, A. (2000). Strategic networks. Strategic management journal, 21 (3), 203-215.
Hackett, J., Glidewell, L., West, R., Carder, P., Doran, T., & Foy, R. (2014). Just another incentive scheme’: a qualitative interview study of a local pay-for-performance scheme for primary care. BMC family practice, 15 (1), 168.
Herzlinger, R. E. (2006). Why innovation in health care is so hard. Harvard business review, 84 (5), 58.
Kaplan, R. S., & Porter, M. E. (2011). How to solve the cost crisis in health care. Harv Bus Rev, 89 (9), 46-52.
Kessels, R., Van Herck, P., Dancet, E., Annemans, L., & Sermeus, W. (2015). How to reform western care payment systems according to physicians, policy makers, healthcare executives and researchers: a discrete choice experiment. BMC health services research, 15 (1), 191.
Khanduja, K., Scales, D. C., & Adhikari, N. K. (2009). Pay for performance in the intensive care unit— opportunity or threat?. Critical care medicine, 37 (3), 852-858.
Kirsh, S. R., Aron, D. C., Johnson, K. D., Santurri, L. E., Stevenson, L. D., Jones, K. R., & Jagosh, J. (2017). A realist review of shared medical appointments: How, for whom, and under what
28
Kroneman, M., Boerma, W., van den Berg, M., Groenewegen, P., de Jong, J., van Ginneken, E. (2016). Netherlands Health system review [PDF file]. Retrieved from
http://www.euro.who.int/__data/assets/pdf_file/0016/314404/HIT_Netherlands.pdf
Lester, H., Matharu, T., Mohammed, M. A., Lester, D., & Foskett-Tharby, R. (2013). Implementation of pay for performance in primary care: a qualitative study 8 years after introduction. Br J
Gen Pract, 63 (611), 408-415.
Linnean. (n.d.). Retrieved June, 2019, from https://linnean.nl/linnean-initiatief/
McClellan, M. (2011). Reforming payments to healthcare providers: The key to slowing healthcare cost growth while improving quality?. Journal of Economic Perspectives, 25 (2), 69-92.
McDonald, R., & Roland, M. (2009). Pay for performance in primary care in England and California: comparison of unintended consequences. The Annals of Family Medicine, 7 (2), 121-127.
McDonald, R., Boaden, R., Roland, M., Kristensen, S. R., Meacock, R., Lau, Y. S., ... & Sutton, M. (2015). A qualitative and quantitative evaluation of the Advancing Quality
pay-for-performance programme in the NHS North West. Health Services and Delivery Research, 3 (23)
Milstein, R., & Schreyoegg, J. (2016). Pay for performance in the inpatient sector: A review of 34 P4P programs in 14 OECD countries. Health Policy, 120 (10), 1125-1140.
Navathe, A. S., Volpp, K. G., Caldarella, K. L., Bond, A., Troxel, A. B., Zhu, J., ... & Nelson, C. (2019). Effect of Financial Bonus Size, Loss Aversion, and Increased Social Pressure on Physician Pay-for-Performance: A Randomized Clinical Trial and Cohort Study. JAMA network open, 2 (2), e187950-e187950.
Nichols, G. A., Bell, T. J., Pedula, K. L., & O'Keeffe-Rosetti, M. (2010). Medical care costs among patients with established cardiovascular disease. The American journal of managed care, 16 (3), 86-93.
29
Pawson, R. (2006). Evidence-based policy: a realist perspective. Sage.
Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2005). Realist review-a new method of systematic review designed for complex policy interventions. Journal of health services
research & policy, 10 (1), 21-34.
Porter, M. E. (2009). A strategy for health care reform—toward a value-based system. New England
Journal of Medicine, 361 (2), 109-112.
Porter, M. E. (2010). What is value in health care?. New England Journal of Medicine, 363 (26), 2477- 2481.
Porter, M. E., & Teisberg, E. O. (2006). Redefining health care: creating value-based competition on results. Harvard Business Press.
Qruxx. (n.d.). Retrieved February, 2019, from https://www.qruxx.com/
Ridgely, M. S., De Vries, D., Bozic, K. J., & Hussey, P. S. (2014). Bundled payment fails to gain a foothold in California: the experience of the IHA bundled payment demonstration. Health
Affairs, 33 (8), 1345-1352.
Ronning, P. L. (2010). ACOs: preparing for Medicare's shared savings program: healthcare reform has placed the concept of accountable care on the agenda. It's now up to providers to decide whether, or perhaps more to the point, how they will participate in Medicare's shared savings program. Healthcare Financial Management, 64 (8), 46-52.
Skipr. (n.d.). Retrieved February, 2019, from https://www.skipr.nl/
Tranfield, D., Denyer, D., & Smart, P. (2003). Towards a methodology for developing evidence‐ informed management knowledge by means of systematic review. British journal of
management, 14 (3), 207-222.
30
year longitudinal case studies in 2 Italian regions. The International journal of health planning
and management, 33 (2), 474-484.
Van Herck, P., Annemans, L., De Smedt, D., Remmen, R., & Sermeus, W. (2011). Pay-for-performance step-by-step: introduction to the MIMIQ model. Health policy, 102 (1), 8-17.
Van der Pennen, R., Putters, K., & Berden, B. (2015). Imperfect performance: A case study on the pay-for-performance instrument for physicians in Dutch hospitals. Administration & Society, 47 (7), 881-909.
Vlaanderen, F. P., Tanke, M. A., Bloem, B. R., Faber, M. J., Eijkenaar, F., Schut, F. T., & Jeurissen, P. P. T. (2019). Design and effects of outcome-based payment models in healthcare: a systematic review. The European Journal of Health Economics, 20 (2), 217-232.
Werner, R. M., Kolstad, J. T., Stuart, E. A., & Polsky, D. (2011). The effect of pay-for-performance in hospitals: lessons for quality improvement. Health Affairs, 30 (4), 690-698.
Williams, I. (2011). Organizational readiness for innovation in health care: some lessons from the recent literature. Health Services Management Research, 24 (4), 213-218.
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Appendix
Appendix 1: Literature codes
Article # Context Mechanisms Outcome
1 NHS, context of heavy workloads, competing priorities, frontline staff did not always adhere to AQ requirements, data collection, voluntary, hospitals implemented AQ using a range of activities tailored to and
developed in their local context, intrinsic motivation
Financial incentives short term no penalties (long term with penalties), Strong network structure, In-person
collaborative learning events, dedicated infrastructure support, collaboration to facilitate learning, program participants were able to contribute to shaping the program, persistent and focused individuals, data collection
Successful enhanced outcomes for patients, decreased mortality rates, short term effect, no long term evidence, spill-over effects
2 US primary care physician, hospital, chronic care, part of a quality improvement program, low SES, large budget
Increasing bonus size (financial)
Physicians feel loss of autonomy, disconnecting from the program,
undermines their profession and its values, improved quality of care for patients, mismatch between parties 3 US Small practices (less
than 10 physicians), supported by EPR, p4p design paid per individual patient
Paid for meeting benchmark, EPR enabled participants to respond to incentives,
Modest improvements in cardiovascular care processes and outcomes (blood pressure and cholesterol control) 4 England primary care
GPs, long term horizon, National program, benchmark data available
Routinization of pay for performance into primary care work, inclusion of important parties. Financial incentives linked to physicians pay
Some loss of medical professionalism/clinical autonomy, minority of GPs felt disconnected from the program
5 England primary care GPs, local
pay-for-performance scheme, High/low SES. alcohol, learning disabilities, chlamydia, obesity, osteoporosis
Credibility of incentivized targets, tensions
within consultations, changing professional identity and roles
32 6 England and California,
primary care, complex contracting
Lack of awareness of relationship between performance and incentive payments (multiple parties) in California, EPR (England), larger number of performance measures, bad communication and little autonomy care providers (California). English physicians are assessed using data extracted from their own medical records,
Californian physicians resentment about pay for performance and less motivated to act on financial incentives, even in the program with the highest rewards, feeling detached from program frustration, disenrollment, lack of understanding, and lack of ownership reported by Californian physicians 7 US hospitals, acute care,
heart failure, senior managers and cardiologists at ten hospitals involved
Hospital setting, resource availability, and existing quality improvement infrastructure. Financial rewards were not allocated to individuals but rather groups and a general fund. Room for improvement must be present, sufficient support, EPR support
The incentive was not a primary factor in driving or sustaining quality
improvement efforts, incentives were a relatively weak motivation for effort. Results were driven by a desire to provide the best care possible, outcomes are argued to be context dependent
8 Us Acute care hospitals, acute myocardial infarction, heart failure, and pneumonia, complex measuring program
Large incentive size, level of competition, supported by sufficient resources
Only short term effects, long term effects not supported,
9 Spain, Barcelona primary care for upper middle class, design on top of current payment system, quality
improvement culture, voluntary, high commitment
supervised process,
performance was agreed on between the professional and team leader, scorecards introduced, incentives were up to 25 percent of the total payment, multidisciplinary quality-improvement groups, communication strategy, continuous learning
Indicators were sometimes misunderstood by the professionals, change of organizational structure needed, availability of information led to an excess of information 10 Netherlands, general practices, diabetes + COPD and cardiovascular risk management
Practice type, bottom-up developed P4P program, target users involved
Inconsistent finding on enhanced quality of care
11 US Hospitals, heart failure or pneumonia, heart attack admission, medium/large hospitals
Extensive support during the implementation
33 12 Dutch hospitals, relation
between board and physician
Financial incentive based on physicians’ own notion, lack of awareness, lack of task
distribution and
implementation strategy
Physicians feel restrained, loss of autonomy due to the instrument, the
effectiveness of a one-sided policy will be unlikely to succeed from the start, miss match between involved parties, no significant positive effects 13 France, hospitals, little
relational links between providers
Position within the
organization, lack of clarity, time constraints, lack of resources
Lack of awareness about the program, little to no effect
14 Italian, performance measure in place, healthcare is decentralized and regional, 2 cases
Engagement of the people who work in it , frequent of rewards (high awareness), systematic use of clinical indicators, target setting process, benchmarking and transparent public disclosure
Two cases both showed improvements, p4p more effective for intermediary outcomes than for pure outcome indicators, no impact by frequently rewording, received
feedback on how they were doing more frequently 15 Inpatient across the
world
A clear aim and
implementation strategy, clear target levels, indicators that are aligned with outcomes, aligned financial incentives
34
Code Grounded Code Groups
● Communication 32 Mechanisms - Relational based
Mechanisms - High level of collaboration
● Current included parties 30
● P4P - Design 29 Progam design
● Availability of outcome indicators for patients 21
● Availability of benchmark 19
● Resistance 18 Mechanisms - Motivation
● start initiative 17
● Factors - Succesfactors 14
● Support for program 14 Mechanisms - Relational based
Mechanisms - High level of collaboration
● Factors - Impedement 13
● Intrinsic motivated participants 13 Mechanisms - Relational based Mechanisms - Motivation
● Close fit to context 13 Progam design
● Dissamination of innovation 12
● Context focus 12 Progam design
● Task distribution 11 Mechanisms - Relational based
Progam design
Mechanisms - High level of collaboration
● Trial and error 10
● Intrinsic motivation initiator 10
● P4P - No, Financial incentive to imporve - Yes
9 Progam design
● Measure outcomes 9
● Degree of standardized care 8 Progam design
● Idea sharing 8 Mechanisms - Relational based
Mechanisms - High level of collaboration
● Availability of patient data 8
● Incentive similarities BP and P4P 8
● Measurement complexity 8
● The urge to start VBP 7
● Goal 7
● Volume 7
● Hard to measure finances 6
● Future included parties 6
● Risk management 6
● Feasibility 6
● Trust 6 Mechanisms - Relational based
Mechanisms - Motivation
Mechanisms - High level of collaboration
● P4P - Shared savings 6 Progam design
● Linking financial and quality together 5
● Future goals 5
● High level of outcome variation between providers
4
● Third party management involvement 4 Progam design
● Lack of Support 4 Mechanisms - Relational based
● Outcome 4
● Continious improvement 3
● Clear implementation approach 3 Progam design
● Availability of data 3
● Collaboration 3 Mechanisms - High level of collaboration
● Volume - winst 3
● involved with the program since 2
● Importance of costs in VBP 2
● Insurers 2
● Plannable care 2
● Availability of resources 2
● Just start 2
● Innovation in care payment to reduce costs 1
● Unknown with VBHC Porter 1
● No urgency to start 1
● Focus - Quality of care 1
● Just start -Small 1
● Treatment complexity 1
● Initial level of care 1
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Appendix 3: Interview protocol (Dutch)
Naam: Organisatie: Functie:
Naam van het praktijkvoorbeeld:
Beschrijvingen van het initiatief
Wat is uw betrokkenheid bij het initiatief? Wie waren er betrokken bij het initiatief? Welke zorginkoper van zorgverzekeraar?
Welke zorgverleners/ organisaties (1 of meerdere)? In welke mate zijn patiënten betrokken?
Wat was de aanleiding om te starten? Welk probleem wil je oplossen?
Waar kwam het initiatief vandaan?
Waarom is de keuze gevallen op dit ziektebeeld?
Acuut vs elective
Wat zijn bepalende factoren geweest in de opzet van het initiatief? In welke fase zit het initiatief?
Te starten – pilot – implementatie – evaluatie
Wie had het initiatief, wie waren de leidende coalities? Was er een speciale aanleiding of urgentie? Was u bekend met de betrokken initiatiefnemers?
Bekostiging
Hoe ziet het inkoopmodel eruit?
Wat zijn de incentives/ (financiële) prikkels geweest?
Virtueel (ongewijzigde declaratie systeem, daar bovenop afspraken gemaakt) of cash (geboortezorg, onderliggende declaratiesysteem aanpassen, vertraging)
Looptijd van het contract Was er een investering nodig?
Was er sprake van een bonus of P4P? Follow up: hoe is deze verdeeld? Welke zorg valt onder de contractering?
Voor welke aandoening(en)? Voor welke behandelingen?
Waren er bepaalde voorwaarden of excludatie criteria?
Voor welke sector? (ziekenhuis, verpleeg en verzorging, gehandicapten, geestelijke gezondheidszorg, 1e lijn, overig)
Patiëntenpopulatie
Waren patiënten of was een patiëntenorganisatie betrokken bij het initiatief? Is er gecorrigeerd voor casemix?
Wat gebeurt er met outliers? (extreem dure patiënten, waar ligt afkappunt). Wat gebeurt er al een patiënt toch liever een ander zorgpad kiest?
36 Vaak wordt risico selectie genoemd, was hier sprake van?
Denkt u dat er een belang is voor de huisarts in de voorspelbaarheid van de ziekte of aandoening? Hoe worden kosten van de patiëntenreis gemeten?
Hoeveel zorgkosten?
Financiële waarde van het initiatief. Bv, meer heeft gekost, maar had toegevoegde waarde? Hoe worden de kosten gemeten?
Bepaling van waarde
Worden de uitkomsten/ kwaliteit gemeten?
Betere ervaren kwaliteit van zorg versus gemeten kwaliteit
Gezondheidsbeleving verbetert, emotioneel traject, geen bewijs voor, hoe vertaal je dit in een goede balans tussen gecreëerde waarde en kosten?
Welke normen worden gehanteerd?
bv minimaal 80% patiënten x gehaald (absoluut), of behoren bij de 20% beste (relatief) Waren er bepaalde onderdelen van VBHC (Value Agenda) waar de nadruk op lag? Implementatie
Wat waren succesfactoren of belemmeringen? Evaluatie
Zijn resultaten geëvalueerd? Publicaties, links en bijlagen:
Is er meer informatie over dit initiatief bekend?
Zijn er meer belangrijke stakeholders binnen dit initiatief die belangrijk zijn voor ons onderzoek? Wat is je belangrijkste tip aan anderen/ andere organisaties die ook een bundled payment/P4P initiatief willen implementeren?
Voorbeelden wat niet gelukt is. Wat had anders gekund? Mogelijkheden tot standaardisatie/opschaling:
Is het praktijkvoorbeeld volgens u 1 op 1 over te nemen door andere partijen of in vergelijkbare situaties? Als u nog een keer bezig zou gaan met bundled payment of P4P, wat zou u dan juist willen meenemen of anders willen doen? Zou u kiezen voor hetzelfde ziektebeeld, dezelfde samenwerkingspartners, of een andere keuze?
